Provider Demographics
NPI:1891833869
Name:HOLLIWAY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:HOLLIWAY MEDICAL CLINIC LLC
Other - Org Name:HOLLIWAY PEDIATRIC CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRONDWYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HOLLIWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-635-8606
Mailing Address - Street 1:3824 HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103
Mailing Address - Country:US
Mailing Address - Phone:318-635-8606
Mailing Address - Fax:318-635-1265
Practice Address - Street 1:3824 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-635-8606
Practice Address - Fax:318-635-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1966207Medicaid
LA1449423OtherGROUP #
LA5R787Medicare ID - Type Unspecified
LA1449423OtherGROUP #